Thursday, December 22, 2005

Abusement Park

There is a vicious circle of a sizeable number of repeat drug offenders going in and out of rehabilitation and jail. Once out, they are back with their own kind, scouring the island for clinics willing to supply them with sleeping pills, Subutex, codeine cough mixtures and painkillers, and tranquillisers.

Addiction recognises no social or professional barriers. For obvious reasons, there will always be someone willing to supply addicts with drugs if you refuse to. Then the doctors who prescribe 'too freely' get hauled up by the Singapore Medical Council. The addicts then go on an islandwide merry-go-round looking for other drug sources, and the cycle repeats itself without the root cause of the problem being addressed.

Yes, we have the Community Addictions Management Programme (Camp), but how many people know the hotline number or where the so-called 'We Care' centre is? These clinic junkies will not seek help voluntarily and the problem will never be solved unless Camp is more proactive in its efforts.

You get stressed-out executives hooked on Dormicum or Nitrazepam, or hear of people telling you they have accidentally spilled their cough mixtures and need some more. Some even go to the extent of looking after other people's babies, and claiming they cannot sleep because of the crying at night.

The authorities or Central Narcotics Bureau should suggest where doctors can send these hopelessly hooked codeine junkies and stop their perennial merry-go-round game with clinics. Otherwise doctors will get hauled up regularly for prescribing sleeping pills or codeine-based cough mixtures too freely, and the problem never gets solved.

Dr Lim Boon Hee

Dr Lim seems to have identified the problems, but I don’t think the solution he proposes will work.

The primary problem is: “junkies will not seek help voluntarily”. Add to that the fact that “there will always be someone willing to supply addicts with drugs”, what you have is a perfect working relationship that neither party has reasons to break. Those who refuse to prescribe to known or suspected junkies (bearing in mind that ‘under Regulation 19 of the Misuse of Drugs Regulations, a doctor who attends to a person who he considers or has reasonable grounds to suspect is a drug addict shall, within 7 days of the attendance, furnish details of the person to the Director of Medical Services (DMS) and the Director of the Central Narcotics Bureau (CNB).’) will not “get hauled up by the Singapore Medical Council”.

Those who do prescribe ‘too freely’? Well, under the Misuse of Drugs Act, ‘(a)ny person who abets the commission of or who attempts to commit or does any act preparatory to, or in furtherance of, the commission of any offence under this Act shall be guilty of that offence and shall be liable on conviction to the punishment provided for that offence.’

Fact is, doctors know it is wrong to prescribe to addicts, that it is wrong to not inform the authorities (there is even a clause in the Act to protect the informant’s identity), and they know whom to notify.

So I don’t think doctors are innocent victims in this relationship who get hauled up to the Medical Council for no good reason at all. If the addicts are the ones going on a merry-go-round ride, the doctors are the ones collecting admission into the Abusement Park.

10 Comments:

We are a wired society.

Why is it not possible to have the particulars of patients who are prescribed addictive drugs put on a secured online database so that every doctor on the island knows about his nefarious ways to get his fix.

Patient confidentiality is no longer valid because his addiction affects the country and it is every body's business to contain him.

What a frightening system you live in in Singapore. You are required by law to report, to what sounds like a police organisation, all suspected of drug misuse ? How do you feel about this ethically, as a physician ? Do you think this is, perhaps, potentially harmful to the wellbeing of your patients ? Which is the higher priority ?

Are all 'drug addicts' lost causes ? Freud was hooked on cocaine in colas at the time, Van Gogh on absinthe...would we be better off as a society had they been expunged ?

Tobacco is highly addictive, and the leading preventable cause of heart disease and cancer...the leading killers in all developed nations. Should smokers be placed on a register and refused treatment ? Should the obese, who in effect are addicted to overeating (or perhaps underexercising) be excluded from care for their diabetes, hypertension, or heart disease ?

"How do you feel about this ethically, as a physician? Do you think this is, perhaps, potentially harmful to the wellbeing of your patients? Which is the higher priority?"

Culturally, we (doctors) are brought up to know that the law overrides patient confidentiality in public health and drug-abuse cases. It's not a big ethical issue to most of us, I suspect.

In practice, however, we know our way around the system. Some laws are just there for historical reasons and people are rarely if ever prosecuted under them (like say the law on suicide, for example).

Personally, I know that if I am willing to break the law for a patient, I must be willing to face the consequences.

"Are all 'drug addicts' lost causes? Freud was hooked on cocaine in colas at the time, Van Gogh on absinthe...would we be better off as a society had they been expunged?"

No, but MOST drug addicts are not Freud or van Gogh, and most scientists and artists contribute to mankind WITHOUT abusing drugs. :)

"Tobacco is highly addictive, and the leading preventable cause of heart disease and cancer...the leading killers in all developed nations. Should smokers be placed on a register and refused treatment? Should the obese, who in effect are addicted to overeating (or perhaps underexercising) be excluded from care for their diabetes, hypertension, or heart disease?"

As I have mentioned many times, a person's health only becomes a public issue because of pooled risk from subsidised healthcare and insurance.

I don't believe anyone should be denied healthcare, but believe people should be made accountable for their health.

Thanks for the replies guys. On re-reading my post it seemed a tad abrasive, apologies.I can see quite a cultural divide indeed. I guess here in oz, privacy law strongly protects the confidentiality of the doctor-patient relationship. To my mind, this means patients can be honest about all matters affecting their health without fear of legal consequence...in my opinion, this is a good thing, as patient care is improved by less withholding of information...as many who turn to drugs often do so as a consequence of untreated mental illness. I agree that certain diseases should be notifiable in the public interest, for community health surveillance...but if we 'called the cops' on a patient who was using drugs, we would be struck off the medical register.

To quote Hippocrates:"What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about."

It's a difficult debate, and there is no clear solution that I can see. In essence, we have a form of prohibition here in oz as well, just our penalties aren't quite as...harsh.

Here's a curly one: What would you do, if you saw a patient addicted to benzodiazepines, who was entering into imminent withdrawal (which, to the non-medicos out there, can be fatal), and you were the only doc around to treat them ?

I think it's just a matter of the law of the land. The law spells it out quite clearly for us so that if we do report for the sake of the patient, we won't be sued.

I just today received a Directive from the Ministry requiring us to notify Bird Flu. On suspicion.

"Here's a curly one: What would you do, if you saw a patient addicted to benzodiazepines, who was entering into imminent withdrawal (which, to the non-medicos out there, can be fatal), and you were the only doc around to treat them?"

Treat first, ask questions later, as always. Like I said much of the law is there 'just in case' and are rarely invoked. The legal system here is actually quite lenient towards doctors, despite what Dr Oz Bloke might make you believe. :)

(Most cases are settled out of court not because hospitals are afraid to lose, but because the cost of fighting the case would be higher than the pay-out.)

I had previously 'tampered with a crime scene' to save a patient. No biggie.

well, the way i figured it, the law is an attempt by human being to make sense of a crazy world. the basic intentions are usually good, for example, keeping general law and order. as with all human endeavor, it has its imperfection. but what to do? without it, we would grope about in even greater darkness and anarchy. we can rant all about injustices and personal misgivings, after all, the law doesn't equal to justice, it's just an attempt at justice.what matters, me thinks, is the intention or motivation of our actions. why we do what we do is important. to me, so long as i have no troubles sleeping at night, then i'd have no problems at all despite what the law says...